plen 01506 333 129 Mon - Sat: 8.30 - 17.00
Broom House, Quarrywood Court, Livingston EH54 6AX
plen 01506 333 129 Mon - Sat: 8.30 - 17.00
Broom House, Quarrywood Court, Livingston EH54 6AX

Patient Questionnaire

Complete the patient's details before the visit.

    Date of appointment:


    Date of Birth:
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    Name of the practice (No required):







    Head Injuries
    Anaemia
    Heart Murmurs
    Arthritis
    Hight Blood Pressure
    Artificial Joints
    Heart Disease
    Artificial Heart valves/vessels
    Kidney Disease
    Asthma
    Liver Disease
    Blood Disease
    Mental Disorders
    Cancer
    Nervous Disorders
    Diabetes
    Pacemaker
    Dizzoness
    Problems with stomach
    Epilepsy
    Excessive Bleeding
    Respiratory Problems
    Rheumatic Problems
    Fainting
    Radiation Treatment
    Fever
    Stroke
    Glaucoma
    Thyroid Disease
    Hay Fever
    Tuberculosis
    Hepatitis
    Ulcers


    Allergies


    Drug allergies


    Have you ever been told to Pre-Medicate (take antibiotics) before taking bloods?


    Do you use tobacco in any form?


    How would you describe your present health?


    Have you been admitted to a hospital or needed emergency care during the past year?


    Are you now under the care of a physician?



    Are you taking any medications (This includes over the counter drugs)?


    Do you have any health problems that need further clarification?:







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    Our Clinic

    Phone

    01506 333 129

    Facebook

    KAL-Med Consulting
    @kalmedconsulting

    Address

    KAL-Med Consulting

    Broom House
    Quarrywood Court
    Livingston
    EH54 6AX

    E-mail

    reception@kalmed.co.uk

    Enquiries and Appointments:
    Mon. – Sat.: 8.30 – 17.00

    How to get to our clinic?

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